Management of Heart Failure 2013

Theo E. Meyer MD DPhil Chief of Clinical Cardiology Director Advanced Heart Failure Program UMMHC

Challenges in 2013 No significant advances in last 5 years

or so. Focus on cost of HF care

Appropriate use – ICD, BiV Devices and Angiography

Readmission rates Multiple providers- limited communication

Aging population: Polypharmacy Impact; benefit versus risk. EOL

Life of a HF patient

ED Hospital Discharge

Home

Rehab Facility

Office

Case Discussion. 55 yr old male presents to

the outpatient clinic with hx of 4 months progressive SOB and orthopnea.

No hx of CP, syncope or leg edema

PMHx: OSA, Morbid obesity, DM2, OA of R knee.

Non-smoker, no family hx of HF

Meds: Avandia 4 mg po qday, Ibuprofen 400 mg tid .

Exam: BP 105 / 65 ; p=90 bpm, O2 sat 92%

JVD elevated S4 No murmurs Decreased air entry both

lung bases, inspiratory rales

Abdomen soft Trace leg edema

Labs:

Cr 1.4 Na+ = 134 HbAic=10.3% HCT= 38%

ECG

What next? Additional tests? Diagnosis Contributing factors? Treatment regimen? Which drugs first?

Echo: Large anterior

dyskinetic area. EF25% Moderate MR Preserved RV

function? Cath:

LAD occluded proximally

60% Mid LCx 50-70% Mid RCA

Follow-up FCII Meds:

Captopril 12.5 mg tid Carvedilol 12.5 mg po

bid Spirinolactone 12.5 mg

qday Bumetamide 2 mg qday ASA 81 mg qday Simvastatin 40 mg qday Metformin 500 mg qday

Target doses? Role of coumadin? Risk of sudden death? Role of digoxin? Aneurysmectomy? Telemanagement? OSA- CPAP?

ICD Guidelines Class I, Level of Evidence A

ischemic cardiomyopathy who are at least 40 days post-MI, have an LVEF of 30% or less, are NYHA functional class I-III on chronic optimal

medical therapy, and have reasonable expectation of survival with a

good functional status for more than 1 year.

ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with

Supporting Clinical Trials 1. MADIT: Moss AJ. N Engl J Med 1996;335:1933-1940. 2. MADIT-II: Moss AJ. N Engl J Med 2002;346:877-883.

3. MUSTT: Buxton AE. N Engl J Med 1999;341:1882-1892.

Level of Evidence B: Nonischemic cardiomyopathy

Level of Evidence B: Any etiology, FC II-III, EF 30-35%.

Spectrum of HF Mildly symptomatic - Difficult to Dx Syndrome of dry heart failure.

CHF= chronic heart failure Moderate to severe HF (Stage D) Diastolic heart failure (HFPEF) Acute decompensated HF

Normotensive, Hypertensive and Hypotensive

Reality of HF

Disease modifying agents are underutilized and not properly dosed.

Underutilization of ICD / BIV pacemakers

EOL discussions – deferred.

Case Study continued Admitted 3x / last

year for ADHF Triggers for

admission: Dietary and med

noncompliance. AF with RVR Worsening renal

function: Cr 1.7

Vitals: BP 90/60 mmHg; HR =75 regular. Wt=120 Kg.

Mild leg edema. JVD =6 cm.

Meds:

Meds: Captopril 25 mg tid Coreg 25 mg po bid

Bumetamide 2 mg daily Digoxin 0.125 mg daily

Coumadin ASA 325 mg qday

Sprinolactone 25 mg Qday Simvastatin 80 mg qday

Amiodarone 400 mg qday Glyburide 5 mg qday

Diclofenac 50 mg po bid

Questions

Is the patient on guideline proven therapies?

What changes in medications would you propose?

60% of HF are not adherent with medications: 3 triggers to nonadherence: ○ Lapses in attention ○ Daytime sleepiness ○ Taking meds > 2 x / day.

Meds: Captopril 25 mg tid Coreg 25 mg po bid

Bumetamide 2 mg bid Digoxin 0.125 mg daily

Coumadin ASA 325 mg qday

Sprinolactone 25 mg Qday Simvastatin 80 mg qday

Amiodarone 400 mg qday Glyburide 5 mg qday

Diclofenac 50 mg po bid

Meds: Lisinopril 10 mg qday

Metoprolol succinate 200 mg qday Torsemide 60 mg qday Digoxin 0.125 mg daily

Coumadin ASA 81 mg qday

Sprinolactone 25 mg Qday Atorvastatin 80 mg qday

Amiodarone 400 mg qday Glyburide 5 mg qday

Ultram

Other issues

Digoxin levels? Digoxin useful in rate control? HbA1c ~ 8.1% - add other meds? Patients complains of ED? Cialis safe? Potential cause for worsening renal

failure? K+ has increased to 6.0?

What next

Ongoing challenges

Patient becomes more symptomatic. FC III symptoms - SOB, no CP: BP 85/50

mmHg, HR 58 bpm; JVD 8 cm, HPJR; MR murmur. 1+ leg edema.

What would you do next? BNP level? Echo? Change meds?

A-Heft Survival

Taylor AL et al

Emphasis HF study

Interactions Between Baseline Characteristics and Treatments Relative to Main Outcomes

The TIME-CHF study demonstrated that intensified N-terminal BNP–guided heart failure therapy did not improve overall 18-month survival free of any hospitalizations or improve quality of life more than those receiving standard symptom-guided therapy

Evaluation of the Persistently Symptomatic HF patient Medical regimen appropriate?

Drug-drug interaction. Amiodarone and beta-blocker.

Side effects of medications- TSH –Amiodarone.

Structural changes? EF; new MR; new wall motion abnormality Ischemia

Volume status: Define dry weight Role of BNP?

Continued: Arrhythmia’s? New LBBB? Untreated sleep apnea

Development of PHTN. Considerations:

Refer to HF program Consider advance tehrapies.

Sinus node

AV node

LBBB

Left Bundle Branch Block

60%

70%

80%

90%

100%

0 60 120 180 240 300 360

Days in Trial

Cum

ulat

ive

Surv

ival

QRS Duration (msec)

<90

90-120

120-170

170-220

>220

Wide QRS – Proportional Mortality Increase

• NYHA Class II-IV patients • 3,654 ECGs digitally scanned • Age, creatinine, LVEF,

heart rate, and QRS duration found to be independent predictors of mortality

• Relative risk of widest QRS group 5x greater than narrowest

1 Gottipaty V, Krelis S, Lu F, et al. JACC 1999;33(2) :145 [Abstr847-4].

Vesnarinone Study1 (VEST study analysis)

Patient Indications

CRT device:

– Moderate to severe HF (NYHA Class III/IV) patients

– Symptomatic despite optimal, medical therapy

– QRS ≥ 120 msec

– LVEF ≤ 35%

CRT plus ICD:

– Same as above with ICD indication

Cardiac Resynchronization Therapy

Challenges for Managing Decompensated Heart Failure

Worsening renal failure- following treatment with diuretics

Hypotension- following treatment with diuretics and other agents.

Diuretic resistance Contraction alkalosis Best initial treatment in patients with

GFR <20 ml/min? Rate of volume removal?

• General: – Avoid NSAID – Avoid aggressive vasodilator therapy that

reduces renal perfusion pressure • Specific:

– furosemide/ bumetamide, give doses more frequently (same total dose)

– increasing doses more frequently – IV diuretics – continuous infusion (furosemide 5-20 mg/hour)

Management of Resistance to Diuretics

• Specific continued – sequential nephron blockade:

• loop diuretic + thiazide (HCTZ 25 mg/day or metolazone 2.5 mg/day)

• loop+ HCTZ and triamterene (dyazide) • add low dose spironolactone • add ACEI • short term acetazolamide in selected

patients

Does Rising Creatinine Indicate Adequate Decongestion ?

Rising Cr indicates that diuresis has exceeded the plasma refill rate (PRR).

PRR dependent on interstitial and intravascular hydrostatic and oncotic pressures.

Renal function should not worsen provided PRR is not exceeded.

If PRR is exceeded, Cr will rise despite persistent volume overload

Kidney

Interstitial compartment

Vascular compartment

Plasma Refill Rate

Azotemia

Take Home Points

Renal fxn closely related to mortality Congestion- detrimental effects Worsening renal fxn during treatment

for HF portends worse outcome Baseline CVP predicts worsening renal

failure

Medicines to Avoid in HF patients

HTN: α adrenergic blockers: Prazosin Doxazosin (ALLHAT trial)

Minoxidil: Fluid retention CCB

○ Diltiazem / Verapamil ○ Nifedipine / Nisoldipine / Nicardipine

DM: Metformin: FC III and IV HF, poor renal fxn TZD (rosiglitazone and pioglitazone) FC III and IV HF,

Peripheral vascular disease; Cilastozol (phophodiesterase inhibitor)

Challenge 4:

Management of HF with preserved EF.

Owan T et al. N Engl J Med 2006;355:251-259

Secular Trends in the Prevalence of Heart Failure with Preserved Ejection Fraction

Heart Failure with Normal EF

Hypertension Diabetes

Renal Insuff

Diastolic Dysfunction

Aging

Diastolic HF

Management Principles of Patient with Diastolic Heart

failure

• Goals: – Reduce congestion – Prevent tachycardia

and maintain sinus rhythm.

– Treat ischemia – Control Hypertension

• Theoretical Goals – Promote regression

of LVH – Prevent myocardial

fibrosis

1) Fluid retention

2) BP control

3) HR control

4) Ischemia

5) Patient Education

Diastolic Heart Failure Treatment

Diuretics BE CAREFUL

ACE, ARB, B Blocker?diuretics

B Blocker ?Calcium C Blocker

B Blocker / Revascularization

Disease Management

HTN and Renal Failure: Furosemide 60 mg BID

Causes Precipitating Heart Failure with Preserved EF

Challenge 6: Disease Management for HF

Treatment of Decompensated Heart Failure: HF Disease Management Program

85% Reduction

p=0.0001

214 patients 6 months pre-evaluation vs 6 months post-evaluation ACEI dose increased (151 mg), diuresed (4 liters), flexible diuretic, home exercise

Ahmanson-UCLA Cardiomyopathy Center Fonarow JACC;1997;30:725-32

Technology-Assisted Monitoring

Referral to HF program Uncertain diagnosis New onset HF Diagnostic work-up Advanced therapies:

ICD BiV pacers Transplant evaluation Ischemic work-up

○ PCI ○ CABG

Disease management High risk for

readmissions ○ Elderly ○ Single ○ Male ○ CRI ○ Significant diuretic

requirements ○ Patient with TR

Working together

PCP/ FP

CV / HF specialist

A B C D

Stages of HF